Are MOOCs the future of medical education?

Game changer

For future doctors, the rise of MOOCs could be an educational game changer—or not. Medical educators are actively exploring how MOOCs and other online courseware could be incorporated into medical training. They agree that lecture based courses, whether online or in person, can provide only part of a doctor’s education. Yet some foresee an important role for online lectures within that context. “Online content delivery will be commonplace within about five years in medical school,” predicts Catherine R Lucey, who taught the 28 000-student MOOC and who, as vice dean of education at UCSF’s medical school, oversees the university’s undergraduate, graduate, and continuing medical education (CME). Medical students, she says, might never be able to tick off a credit for taking an exclusively web based course, but before and after medical school they may find they can increasingly complete requirements online.

To date, no medical school or premed program seems to have offered academic credit for a MOOC. But in early February, the American Council on Education certified four Coursera courses, meaning that the council now encourages universities to grant undergraduate credit to students who complete them. Just days later, Coursera announced that two other courses, including Clinical Problem Solving, could be counted as CME, as long as students seeking CME pay a modest fee and submit to an optional process for identity verification. These two courses seem to be the first MOOCs eligible for CME credit.

In Aschenbrener’s case, getting credit is beside the point. She’s gainfully employed as the chief medical education officer of the Association of American Medical Colleges. The association represents 141 accredited US medical schools and about 400 affiliated teaching hospitals, the very institutions where US medical students and residents learn their art. Yet like her UCSF professor, Aschenbrener believes that parts of their medical education may be poised to migrate to the web. Medical schools, she notes, are increasingly shifting away from students attending lecture-format classes, opting instead to steer classroom time toward interaction driven learning. Some schools have introduced an “inverted” or “flipped classroom” model in which students watch prerecorded lectures online in their own time before showing up in class.

Why waste time at a lecture?

A 2012 essay in the New England Journal of Medicine heartily endorsed the use of the flipped classroom model in medical education. “In an era with a perfect video-delivery platform [online], why would anyone waste precious class time on a lecture?” wrote Charles G Prober, Stanford School of Medicine’s senior associate dean of education, and Chip Heath, business professor and one of the authors of “Made to Stick.”2 The pair cited some evidence, including unpublished Stanford data, suggesting that flipped classes engender greater student engagement and better absorption of material.

But a flipped classroom is not the same thing as a course conducted exclusively online, such as a MOOC. Medical educators are quick to emphasize that nearly all courses in modern medical school curriculums are built around interactive learning experiences, some of which—such as mock-patient encounters—are impossible to fully reproduce online. For that reason, experts generally don’t foresee a departure from today’s campus based training of medical students. Some students, Prober says, might be able to power through medical school in fewer than four years, thanks to the easy availability of core knowledge online. But they’ll still need the practical experience they can only get in person.

In the long run, Lucey predicts, “medical schools will either develop courses to be taken online or license courses from other schools.” But either way, she says, these flipped classroom modules will be augmented with in-class interactions at the institution where each student is enrolled.

Johns Hopkins University long ago began experimenting with the flipped classroom approach. It’s been 15 years since molecular biophysicist Harry Goldberg and a team of his faculty colleagues made taped lectures available to medical students taking a course on cardiovascular physiology. Now, the university offers one of academia’s more comprehensive online course catalogs in the health sciences. Through the university’s Bloomberg School of Public Health alone, more than 200 000 students have enrolled in online classes. Several thousand have taken them for credit, in some cases while living and working in farflung corners of the globe.

How big will MOOCs get?

Although Goldberg, now assistant dean at the university’s School of Medicine, sees promise in online learning, he’s skeptical it will revolutionize how tomorrow’s doctors learn. “MOOCs have a role in medical education,” he says. “I think that role is a lot smaller than people hope it will be.” That’s mainly because lecture-style didactics—or “content delivery,” in the parlance of the web—is a small piece of the overall learning experience in medicine. MOOCs permit interaction but not necessarily to the extent that medical education requires, he says.

One place where MOOCs might come into their own is in preparing undergraduates for medical school. Premed courses are often lecture based and information dense, two attributes that play to MOOCs’ strengths, as students can replay a lecture until they understand it. Aschenbrener envisions students being able to satisfy some premed competency requirements through MOOCs instead of classroom time. An undergraduate who completed enough mathematics MOOCs, for example, might be able to earn his or her BA in three years, saving himself or herself time and tuition dollars. (MOOCs also might help weed out weaker would-be doctors before they spend money on tuition for premed classes that they might fail to complete.) “The ultimate goal is not to replace [classroom] learning with this style of learning, but to create greater flexibility,” Aschenbrener says. She hopes MOOCs will help draw more low income students to medicine and perhaps ease the shortage of doctors.

Continuing medical education

Once doctors are in clinical practice, online courses (massive or otherwise) could also help them sharpen their skills and deepen their knowledge. With limitations on working hours for medical residents, Prober says, it can be hard for clinical instructors to assemble all their trainees in the same place at the same time—and they have to repeat the exercise year after year. If their talks were online, instructors could simply have residents watch them and complete a quiz to demonstrate comprehension.

Trainees aren’t the only ones who stand to gain. MOOCs are potentially superior to existing forms of distance CME, such as podcasts of grand rounds, because they enable interaction, including quiz taking, which assists students in mastering the material, and online discussions with fellow course takers. The lack of interaction with patients “isn’t as critical because they are getting the interaction every day in their clinics,” Prober says.

“There’s a huge range in the quality of CME that’s available,” says Andrew Ng, cofounder of Coursera. MOOCs developed by medical schools and offered as CME to their alumni and other doctors are likely to be of high quality, he says. This is particularly the case where a faculty member may have unique and important findings to impart to fellow practitioners—but not enough opportunities at professional meetings or grand rounds to share them. In delivering such CME online, Ng says, “there’s potential for much more rapid dissemination of medical innovation.”

MOOCs could also benefit medical pedagogy. Lucey of UCSF sees them as a highly efficient way for faculty to share teaching techniques directly with one other. “We do that now by writing a paper or going to a meeting,” she says. About 200 of her MOOC students have indicated they are faculty members at other US medical schools. That, she says, “suggests [faculty members] are taking this course to either (a) see how a MOOC works, or (b) see how other people teach clinical problem solving.”

Obstacles to growth

Several hurdles stand in the way of wider use of MOOCs in medicine. “The greatest obstacle, of course, is tradition,” says Aschenbrener. Although some faculty and schools will be open to experimenting, others may fear the challenge of adapting to new teaching methods, not to mention possible new financial pressures. Importantly, there are limited data on how well MOOCs educate students. Prober, despite his enthusiasm for online lectures, says it’s appropriate for skeptics to demand more evidence of their effectiveness. He also notes that different faculty members and schools have divergent ideas about the best way to teach any given medical topic. Bringing them to a consensus that enables them to share courseware across institutions will be a challenge.

Nevertheless, online courses shouldn’t be ignored. “To working professionals, there’s something appealing about the convenience of an online course,” says Ng. A busy clinician, for example, might catch a 20 minute lecture in the window created by an unexpected cancellation. MOOCs, he says, “are bringing a lot of working adults back into the education system.” That’s certainly true of Aschenbrener. “I’m a big fan of MOOCs,” she says. “I’m signed up for four more in the next 12 months.”